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A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
- A. Idea of reference
- B. Delusion of infidelity
- C. Auditory hallucination
- D. Echolalia
Correct Answer: A
Rationale: The correct answer is A: Idea of reference. This patient's belief that the doctors were plotting to kill him is an example of an idea of reference, a symptom of paranoia common in paranoid schizophrenia. This term refers to the belief that neutral actions or events are directed at oneself. Delusion of infidelity (B) involves false beliefs about a partner's infidelity, not relevant here. Auditory hallucination (C) is false perception of sound, not applicable. Echolalia (D) is the repetition of words or phrases, not seen in this scenario. Identifying the behavior as an idea of reference helps the nurse understand the patient's distorted perception and tailor interventions effectively.
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A community mental health nurse receives a new client for his caseload. The diagnosis of the client is residual schizophrenia. Documentation states that the client has a number of negative symptoms. Which symptom would the nurse expect to assess in the client?
- A. Bizarre, somatic delusions
- B. Disorganized speech pattern
- C. Catatonic posturing
- D. Emotional blunting
Correct Answer: D
Rationale: The correct answer is D: Emotional blunting. In residual schizophrenia, negative symptoms are prominent, including emotional blunting which refers to a reduced ability to express emotions. This is commonly seen in clients with residual schizophrenia.
Explanation of why other choices are incorrect:
A: Bizarre, somatic delusions are characteristic of paranoid schizophrenia, not residual schizophrenia.
B: Disorganized speech pattern is a symptom of disorganized schizophrenia, not residual schizophrenia.
C: Catatonic posturing is associated with catatonic schizophrenia, not residual schizophrenia.
The nurse has been working with a patient diagnosed with schizophrenia who experiences auditory hallucinations. The patient relates, 'When I first heard the voices they said nice things about me. Lately, they've changed and they say bad things.' What information has the least impact on therapeutic patient care at this point in the hospitalization?
- A. Do you trust me to help you with the voices?'
- B. Are the voices commanding you to do something?'
- C. How often during 24 hours do you hear the voices?'
- D. Do you hear the voices if you're busy in noisy environment?'
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
A: Asking about trust in the nurse is not immediately relevant as the patient's primary concern is the change in voice content. Building trust is important but addressing the content of hallucinations takes priority.
B: This is relevant as commanding voices could pose a safety risk.
C: Monitoring frequency helps assess severity and response to treatment.
D: Understanding triggers for hallucinations is important for managing symptoms.
A nurse is caring for a patient with bulimia nervosa who has not eaten for 24 hours. The nurse should first:
- A. Encourage the patient to eat a full meal immediately.
- B. Assess the patient's vital signs and hydration status.
- C. Provide the patient with a menu to select food for the next meal.
- D. Contact the physician for a medication prescription.
Correct Answer: B
Rationale: The correct answer is B because assessing vital signs and hydration status is crucial in identifying potential complications from prolonged fasting in a patient with bulimia nervosa. This step helps determine the patient's immediate needs for intervention and guides further care planning. Encouraging the patient to eat a full meal immediately (Choice A) may lead to refeeding syndrome due to electrolyte imbalances. Providing a menu for the next meal (Choice C) is not the priority when the patient has not eaten for 24 hours. Contacting the physician for a medication prescription (Choice D) is not necessary at this point without first assessing the patient's current physical status.
A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
- A. Idea of reference
- B. Delusion of infidelity
- C. Auditory hallucination
- D. Echolalia
Correct Answer: A
Rationale: The correct answer is A: Idea of reference. This term refers to the belief that neutral events are directed at oneself. In this case, the patient's interpretation of doctors talking as a plot against him signifies a misinterpretation of reality. Delusion of infidelity (B) involves belief in a partner's unfaithfulness, which is not applicable here. Auditory hallucination (C) involves hearing voices, not relevant to this scenario. Echolalia (D) is the repetition of words spoken by others, not demonstrated in the patient's behavior. Thus, A is the most appropriate identification for this behavior.
A client in the cardiac clinic tells the nurse that he is concerned about his mother, age 75, who lives alone and seems more forgetful. Which statement would be most indicative that the mother may have Alzheimer's disease?
- A. Mom continues to participate in senior center activities each week.'
- B. Mom insists on cooking and cleaning for herself.'
- C. Mom forgot to pay her utility bills last month.'
- D. Mom refuses to stop driving even though her reaction time is very slow.'
Correct Answer: C
Rationale: The correct answer is C because forgetting to pay bills is a common early symptom of Alzheimer's disease due to cognitive decline affecting memory and executive functions. This behavior indicates difficulty with organizing and managing tasks, a hallmark of Alzheimer's. Choices A and B suggest independence and engagement, which are not necessarily indicative of Alzheimer's. Choice D hints at potential safety concerns but does not directly point to cognitive decline related to Alzheimer's.